While working as an athletic trainer I was frustrated and furious with the constant flow of athletes ‘needing’ certain treatment. I was tired of students and support staff hooking athletes up to every biophysical modality in the athletic training room. Why? They had no clue – it felt good to the athlete, it ‘worked’, it was easy, the coach said to – my blood beginning to boil.

It seemed every injury for all athletes was treated by the wonderful benefits of electrical stimulation. After a quick evaluation the injured body part is surrounded by electrodes and covered with a comfy hot or cold pack. For 20 minutes the athlete sat there with a special tingly, prickly feeling that gives those in pain a warm fuzzy feeling. As a health care provider there is nothing easier than slapping on a few electrodes and walking away for 20 minutes; it’s easy and clients love it. I must admit that I have fallen victim to the persuasive effect of e-stim as both an athlete and health care provider. But it was time to unplug. The overuse of modalities coupled with the under usage of manual therapy and rehabilitation was sickening. So what did I do?

I unplugged it all. I took all of the modalities and put them in one room with one table. It was not to be used unless a valid reason existed to do so. Holy s***, did I make some people mad. Instantly, coaches and athletes, became health care experts saying it was needed. But for the fellow athletic trainers – they understood. It made them learn reasons why to use modalities. It also help them look at the treatment of injuries in another way. This method also enhanced their ability to identify and correct common human movement dysfunction than causes pain.

Before I go further and before those in support of modality usage start throwing data at me, stop. E-Stim (along with the other biophyscial modalities) is a versatile modality, has few contraindications and is a quick easy way to reduce pain in most clients. For this reason e-stim is often the first tool of choice.The effectiveness and subsequent overuse of e-stim, is secondary to pain relief. A structure called the substantia gelatinosa (SG), lies in the IV Laminae of the dorsal horn in the spinal cord. This structure is where nociceptive (pain) fibers terminate and decisions with regards to how pain should be handled are determined. Also terminating in the SG are A Delta fibers (sensory fibers). E-stim has several modulations, but the most common is for a theory called “Gate Control Theory”. Essentially, electrical impulses from e-stim therapy bombard the SG through the A Delta Sensory fibers and over-ride the nociceptive fibers and ‘turn-off’ pain. The pain relief can last from minutes to several hours.

Unfortunately, all too often, athletic trainers try to control pain rather than fix the problem. Rather than spending 20 minutes turning off pain, why not allocate the time to long-term pain relief and correcting dysfunction? Why not spend 20 minutes correcting a muscle imbalance, which will lead to lifelong change and keep athletes out of your athletic training room? All you are doing is putting a band-aid on a problem, unfortunately you have to keep putting that band-aid on everyday for the entire season. I said it before and will say it again – Athletic Trainers need to transition from triage to rehabilitation and optimizing functional movement. However, I understand the problem: it is a time crunch. Athletic training rooms are vastly understaffed – making it difficult to dedicate 20 minutes of rehabilitation time to one athlete, when 3oo are lined up at the door. So we have a time crunch, but there is a solution…

Almost all injuries we see in the athletic training room are a result of: altered length tension relationships, altered arthrokinematics, altered neuromuscular recruitment. Collectively, these issues are what makes up human movement dysfunction. You name the injury – tendonitis, ACL tears, PFPS, fasciitis, MTSS, impingement, rotator cuff pathologies, you get the point – can be linked back to human movement dysfunction. The good is that human movement dysfunction is identifiable, preventable and correctable. The better is that the strategies to correct human movement dysfunction can be done in less than 15 minutes per day.

Yes, I said it – you can perform a 15 minute rehabilitation session. I presented on this topic at the NATA District 10 and District 2 conference and even did a few customized workshops. A colleague presented on the topic at the June 2012, NATA conference. Imagine correcting a problem, preventing injury, or rehabilitating an athlete in 15 minutes per day. That would be better than slapping on a pair of electrodes and setting up hi-frequency biphasic sensory-level stimulation. You will fix the problem and reduce pain. How you ask?

As I said above, human movement dysfunction is often composed of three problems, all which are identifiable during human movement assessments. The assessments will indicate where human movement impairments exist. But lets say for example we have a patient with patellar tendonitis, we would likely see functional impairments somewhere along the lower extremity. Below is a sample program I would do in 15 minutes.

Note this is just a sample program. In the above instance I assumed the client had limited ankle dorsiflexion and muscle imbalance at the hip musculature. The specific human movement impairment will be client and injury dependent. That said, you can follow the same formula and perform rehab in the same amount of time that it takes to perform e-stim. Too often we use the time crunch as an excuse for our failure to perform due diligence as health care practitioner. We have a job – that is to keep athletes healthy. Let’s choose the path that works – not the band-aid.

As a college athlete Stephen Strasburg was one of the most sought after pitchers in the history of baseball. He destroyed opposing batters with a ridiculous fast baseball and off-speed pitches that seemed to roll off of a table. In 2009, he was the number 1 overall draft pick by the Washington Nationals. Soon after he blitzed through the minor leagues with a stat line that made fantasy baseball owners drool. In his major league debut he recorded 14 strikeouts, 0 walks and 2 earned runs. This Superman was real and he had arrived. However, this Superman also had his own kryptonite – the Ulnar Collateral Ligament.

In August, 2010, the Nationals announced that Stephen suffered a torn Ulnar Collateral Ligament (UCL) and would undergo surgery. Recovery from this surgery is at least one year. He was able to come back and finish off the 2011 season, in a limited fashion while in the minor leagues. Finally, at the start of the 2012 season he came back to the big leagues. So far all is well in 2012. He is arguably the most dominant pitcher in MLB. But his time will end in just a few days.

The Washington Nationals Senior Management and Medical Staff have imposed a 160 inning pitch limit on Strasburg to ensure longevity and health. That 160 inning limit will be reached this month – Strasburg will be done for the season. The first place Washington Nationals lose a significant weapon and the late season run and world series may be in Jeopardy.

A pitch limit seems logical – if you are not pitching you can’t get hurt right? If you limit pitches it must prevent damage right? Wrong! There is little to no scientific evidence to support the limited pitch count to prevent injury theory. According to A 2010 study, the maximum pitches thrown in a game declined from highs in the 160s and 170s in the 1980s and 1990s to highs in the 130s in the 2000s (1). However, over that span the number of injuries and times spent on the disabled list has increased significantly. Certainly, this is not data that correlates with limited pitch count.

Some will argue that fatigue brings about mechanical breakdown, which is known to be a cause of injury. However, a study done by Escamilla, et al, found that pitch mechanics did not change during high pitch counts (2). Additionally, the researchers found that shoulder and elbow torque was not effected by fatigue (2). Again, this is not data which supports limited pitch count.

There are studies which discuss recovery time. Kibler, et al, found that glenohumeral internal rotation is deficient for 72 hours after throwing (3). At 72 hours the range of motion returns to baseline levels. Limited internal rotation has been linked to shoulder and elbow pathology. If a pitcher begins to throw prior to obtaining baseline GIR, it can precipitate or worsen injury of the upper extremity.

Performance levels decrease with limited rest. Potteiger et al, examined muscle fiber damage with periods of two or four days of rest. Like the Kibler study, this data shows muscle damage had returned to baseline levels after 72 hours (4). In addition pitchers had less velocity with two days of rest compared to four days (4).

So, the question remains; is sitting Strasburg beneficial to his health? The above data would suggest otherwise. Data suggests recovery times of 72+ hours allows for return of normal arthrokinematics (GIR) as well as reduction of muscle soreness and enzyme levels in muscle tissue (3, 4). When it comes to injury prevention, it appears days off is more important than pitch count. Neuromyofascial hypertonicity, poor recruitment patterns, and suboptimal arthrokinematics are common with pattern overload and these can be corrected with focused rehabilitation.

What are your thoughts? Should he be benched?

References:

Bradbury, JC, and Forman, S. The Impact of Pitch Counts and Days of Rest on Performance among Major-League Baseball Pitchers. J Strength Cond Res. 2012 May;26(5):1181-7.

Shoulder injuries are found in 21% of the adult population. In athletes, especially those who play overhead sports such as baseball, volleyball or tennis, shoulder injuries are much more prevalent. Most of the time these injuries are simply chronic inflammatory issues such as rotator cuff tendonitis or impingement. In these instances your health care provider, athletic trainer, physical therapist or physician may prescribe a non-specific rehabilitation program, which usually works. However if the diagnosis is wrong, rehabilitation may fail.

A differential diagnosis to chronic shoulder inflammation is Suprascapular Nerve Palsy. Suprascapular nerve palsy is a condition in which the suprascapular nerve – sits above the shoulder blade – is entrapped and nerve supply to the supraspinatus muscle and potentially the infraspinatus muscle is cut off. The suprasacpular nerve arises out of the C5/C6 nerve roots and passes through the suprascapular notch under the suprascapular ligament, which lie under the upper trapezius muscle. After it passes through this notch the nerve bifurcates with one branch innervating the supraspinatus muscle and the other branch innervating the infraspinatus muscle.

In some instances, the nerve will get entrapped and cause palsy and subsequent muscle wasting in the one or both of these rotator cuff muscles. The most common cause is nerve compression caused by ganglion cyst in the notch. Athletes, particularly overhead, such as baseball, volleyball, tennis, players are at risk for developing the palsy secondary to rotator cuff tears, repetitive microtrauma, or scarring of the muscle, which in turn entraps the nerve, thus causing palsy.

If palsy occurs there will be weakness for external rotation and Glenohumeral abduction. Pain may or may not be present. The athlete may experience additional shoulder issues such as, tendonitis, subacromial impingement or tears secondary to decreased rotator cuff stability which may cause pain and mask the true injury. Upon evaluation there will likely be visible wasting in the supraspinous or infraspinous fossa when compared bilaterally. If nerve palsy is suspected a surgeon will order an EMG to test nerve velocity and transmission.

Rehabilitation involves focused activation exercises for the rotator cuff muscles, beginning with isometric exercises with progression to single plane, full range of motion strengthening with final progression to multiplanar strengthening. Avoid exacerbating activity such as throwing and overhead movements. If the issue does not resolve decompression surgery will be required.

Like many shoulder pathologies, Suprascapular Nerve Palsy can be prevented. Repetitive motion can precipitate poor joint mechanics and poor muscle activation patterns. A focused program designed to correct muscle imbalances, obtain proper Glenohumeral arthrokinematics and acquire optimal neuromuscular force coupling will help prevent the palsy.

If you have shoulder pain which is not subsiding with traditional therapy, seek a second opinion to find out what else could be going on.

A single joint with altered arthrokinematics can precipitate a kinetic chain domino effect that will wreck havoc on functional human movement. One such joint is the ankle, where altered arthrokinematics has been linked to several forms of human movement dysfunction and subsequent musculoskeletal injury. Specifically, limited ankle dorsiflexion, has been associated with patellar tendionopathy, ipsilateral gluteus medius weakness, plantar fasciitis, medial tibial stress syndrome, contralateral shoulder pathologies, sacroiliac joint dysfunction, recurrent ankle sprains, chondromalacia, ACL tears, Iliotibial band syndrome, increasing frontal plane motion of the knee, external snapping hip syndrome and osteitis pubis (just to name a few). In addition to the aforementioned injuries athletes ware at risk of significant performance declines in overall power, agility, and speed. I am not saying that these are all caused from limited ankle dorsiflexion, but I am saying that limited ankle dorsiflexion can cause these issues.

These issues can create a huge headache for the athlete, health care practitioner, personal trainer or performance coach. So, the question is what can we do that to prevent or treat these dysfunctional patterns or injuries? Simple, increase ankle dorsiflexion. But how? There are several treatment methods so I began thinking what is the single best way to improve ankle dorsiflexion; static stretching, manual therapy, soft tissue release, dynamic flexibility? I could come up with only one solid, and universal one stop treatment option – manual therapy, specifically Movement with Mobilization (MWM). So I found a good research article to review that talks about MWM and the effect it has on ankle dorsiflexion.

Mobilization with Movement (MWM) techniques are commonly utilized to improve joint range of motion and reduce pain. Recent evidence indicates posterior glide of the talus and ankle dorsiflexion is deficient in patients suffering from recurrent ankle sprains. Clinicians have used MWM techniques as an effective tool to increase posterior talar glide and increase talocrural dorsiflexion. The purpose of this study is to evaluate effectiveness of two MWM techniques (weight-bearing and non-weight bearing) for treatment of recurrent ankle inversion ankle sprains.

Study Limitations:

Imaging studies have not been done to validate assessment of posterior talar glide.

Age range was limited to University’s student population age range of 18-27.

Time from injury only 9.4 months (mean) since most recent injury

Methods:

Subjects:

16 subjects (8 male, 8 female) age 18-27 from University of Queensland student population. Subjects must have history of recurrent unilateral ankle sprains, must not have had injury on contralateral side and must not have had injury within the past 6 months.

Dependent Variables:

Posterior Talar Glide – Posterior glide was applied while passively dorsiflexing at the ankle and flexing the knee. Posterior talar glide measured with use of tibial inclinometer.

If you are an athlete, health care practitioner, personal trainer or performance coach and think that your issue might be associated with limited ankle mobility seek out a qualified practitioner. They will be able to identify if dorsiflexion limitations exist and will be able to treat that limitation properly and restore proper function.

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Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS

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